Vesiculobullous eruptions in the elderly represent a diverse range of varying pathophysiologies and can present a significant clinical dilemma to the diagnostician. Diagnosis requires a careful review of clinical history, attention to detail on physical and histomorphological examination, and appropriate immunofluorescence testing. We describe the case of a 73-year-old female who presented to our hospital with a painful blistering skin rash developed over 2 days. Examination of the skin was remarkable for numerous flaccid hemorrhagic bullae on a normal-appearing nonerythematous skin involving both the upper and lower extremities. Histopathology of the biopsy lesion showed interface change at the epidermo-dermal region with subepidermal blister formation, mild dermal fibrosis, and sparse interstitial neutrophilic infiltrate. Immunohistological analysis was significant for positive IgG basement membrane zone antibodies with a dermal pattern of localization on direct immunofluorescence and positive IgG antinuclear antibodies on indirect immunofluorescence. Evidence of antibodies to type VII collagen suggested the diagnosis of epidermolysis bullosa acquisita versus bullous systemic lupus erythematosus (BSLE). A diagnosis of BSLE was made based on positive American College of Rheumatology criteria, acquired vesiculo-bullous eruptions with compatible histopathological and immunofluorescence findings. This case illustrates one of many difficulties a physician encounters while arriving at a diagnosis from a myriad of immunobullous dermatoses. Also, it is important for internists and dermatologists alike to be aware of and differentiate this uncommon and nonspecific cutaneous SLE manifestation from a myriad of disorders presenting with vesiculobullous skin eruptions in the elderly.

Mentions:
A 73-year-old female presented to our hospital with a painful blistering skin rash since 2 days. Her past medical history was significant for hypertension on thiazides, hyperlipidemia, rheumatoid arthritis (not on disease-modifying antirheumatoid drugs), and thrombocytopenia of unclear etiology. She first noticed the rash 2 days ago and noticed the lesions to be sudden in onset, spontaneously occurring, and progressively involving all areas of the body. The lesions were extremely painful to touch, nonpruritic, and would rupture with a bloody discharge. She denied arthralgias, photosensitivity, fevers or chills, cough, sore throat, hemoptysis, diarrhea or vomiting, epistaxis, hematemesis, or melena. Of note, she had been prescribed a course of Bactrim for a urinary tract infection, which she completed 2 days prior to the onset of the rash. She had a similar presentation 2 months ago, when she was admitted to our hospital for an extensive workup of the underlying etiology. Clinical history, then, did not disclose any identifiable medication triggers. She had not experienced any rashes previously in her life. Examination of the skin, on current admission, was remarkable for numerous various-sized flaccid hemorrhagic bullae on a normal-appearing nonerythematous skin involving both the upper and lower extremities, including the palms, axillae, back, and inguinal regions (fig 1). Some of the ruptured bullae had left tender, weeping erosions. A careful examination of her oral cavity revealed ulcers on the palate and buccal mucosa with numerous 2- to 3-mm blood-filled blisters on the tongue. The remainder of her exam was unremarkable.

Mentions:
A 73-year-old female presented to our hospital with a painful blistering skin rash since 2 days. Her past medical history was significant for hypertension on thiazides, hyperlipidemia, rheumatoid arthritis (not on disease-modifying antirheumatoid drugs), and thrombocytopenia of unclear etiology. She first noticed the rash 2 days ago and noticed the lesions to be sudden in onset, spontaneously occurring, and progressively involving all areas of the body. The lesions were extremely painful to touch, nonpruritic, and would rupture with a bloody discharge. She denied arthralgias, photosensitivity, fevers or chills, cough, sore throat, hemoptysis, diarrhea or vomiting, epistaxis, hematemesis, or melena. Of note, she had been prescribed a course of Bactrim for a urinary tract infection, which she completed 2 days prior to the onset of the rash. She had a similar presentation 2 months ago, when she was admitted to our hospital for an extensive workup of the underlying etiology. Clinical history, then, did not disclose any identifiable medication triggers. She had not experienced any rashes previously in her life. Examination of the skin, on current admission, was remarkable for numerous various-sized flaccid hemorrhagic bullae on a normal-appearing nonerythematous skin involving both the upper and lower extremities, including the palms, axillae, back, and inguinal regions (fig 1). Some of the ruptured bullae had left tender, weeping erosions. A careful examination of her oral cavity revealed ulcers on the palate and buccal mucosa with numerous 2- to 3-mm blood-filled blisters on the tongue. The remainder of her exam was unremarkable.

Vesiculobullous eruptions in the elderly represent a diverse range of varying pathophysiologies and can present a significant clinical dilemma to the diagnostician. Diagnosis requires a careful review of clinical history, attention to detail on physical and histomorphological examination, and appropriate immunofluorescence testing. We describe the case of a 73-year-old female who presented to our hospital with a painful blistering skin rash developed over 2 days. Examination of the skin was remarkable for numerous flaccid hemorrhagic bullae on a normal-appearing nonerythematous skin involving both the upper and lower extremities. Histopathology of the biopsy lesion showed interface change at the epidermo-dermal region with subepidermal blister formation, mild dermal fibrosis, and sparse interstitial neutrophilic infiltrate. Immunohistological analysis was significant for positive IgG basement membrane zone antibodies with a dermal pattern of localization on direct immunofluorescence and positive IgG antinuclear antibodies on indirect immunofluorescence. Evidence of antibodies to type VII collagen suggested the diagnosis of epidermolysis bullosa acquisita versus bullous systemic lupus erythematosus (BSLE). A diagnosis of BSLE was made based on positive American College of Rheumatology criteria, acquired vesiculo-bullous eruptions with compatible histopathological and immunofluorescence findings. This case illustrates one of many difficulties a physician encounters while arriving at a diagnosis from a myriad of immunobullous dermatoses. Also, it is important for internists and dermatologists alike to be aware of and differentiate this uncommon and nonspecific cutaneous SLE manifestation from a myriad of disorders presenting with vesiculobullous skin eruptions in the elderly.